Practicing Medicine
Psychological approaches
to the treatment of rapid
ejaculation
Stanley E. Althof
Keywords
Premature
ejaculation
Abstract
Sex therapy
Psychotherapy
Combined
therapy
This article reviews the psychological theories and treatment approaches to premature ejaculation. It also
describes the potential negative psychological effect of this condition on the man and his partner.
Recommendations and guidelines for providing individual and conjoint treatment with the partner are
discussed as is the role of combined pharmacological and psychological intervention. The limitations of
psychotherapy outcome studies are discussed and the success of psychological interventions for
premature ejaculation is assessed from the studies’ data. Finally, suggestions for improving the longterm therapeutic efficacy of psychotherapy are offered. Psychological intervention remains a vital
alternative in the treatment of premature ejaculation. ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Introduction
Stanley E. Althof, PhD
Case Medical School, and
Center for Marital and
Sexual Health of South
Florida, USA
E-mail:
[email protected]
Online 24 May 2006
180
Delaying men’s ejaculatory latency with offlabel selective serotonin reuptake inhibitors
(SSRIs) is relatively straightforward, but restoring men’s sexual confidence and enhancing
sexual relationship satisfaction is more complicated [1]. Pharmacotherapy with SSRIs and
clomipramine has eclipsed the use of psychological interventions to become the treatment
of choice for this condition [2,3]. However, one
of the lessons learned from the ‘‘Viagra revolution’’ for the treatment of erectile dysfunction
was that no matter how efficacious and safe
the medical intervention, medications alone
could not always surmount the psychosocial
obstacles that maintained the dysfunction and
interfered with sexual life [4].
To date, the cause of rapid ejaculation has
not been conclusively determined. Not surprisingly, there are those who advocate for an
entirely biological explanation and those
who insist that it is a wholly psychological
condition. There are also those who believe
that rapid ejaculation may be a cluster, or
continuum, of disorders, some biologically
determined, others psychological in origin.
Even if we were able to unequivocally state
Vol. 3, No. 2, pp. 180–186, June 2006
that a man’s rapid ejaculation is due to biological factors exclusively, he would probably
manifest a psychological response that might
further worsen the condition. Additionally, his
partner may be psychologically affected by
the dysfunction, regardless of the underlying
cause.
Given that psychological factors can either
worsen the condition or in some cases may be
responsible for precipitating and maintaining
the dysfunction psychotherapy remains a vital
intervention to help men and their partners
who suffer from rapid ejaculation. The aims of
this paper are to review the psychological
theories regarding rapid ejaculation and to
discuss psychotherapy\sex therapy as the sole
intervention for the treatment of rapid ejaculation or, in an updated rendering, as part of a
combined or integrated pharmacological/
psychological treatment.
Psychological theories
There are multiple psychological explanations
as to why men develop rapid ejaculation.
Unfortunately, none of the theories evolve
from evidenced-based medicine studies. Rather
ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Practicing Medicine
they are the products of thoughtful synthesis
by clinicians from several schools of thought.
Although untested, the theories are thought
provoking.
In 1927, a German psychoanalyst speculated
that rapid ejaculation is due to a combination
of the man’s unconscious hostile feelings
towards women and his passive pleasure, as
a child, in losing control of his urination
(passive urethral eroticism) which, as an adult,
transforms itself into his passive pleasure in
giving up control of ejaculation [5]. Thus, ejaculation into the woman’s vagina was equated
with ‘‘soiling’’ or ‘‘debasing’’ her. The man
took his sexual pleasure, unconsciously soiled
her, and in so doing deprived her of sexual
pleasure. Simultaneously he gives himself over
to the passive pleasure of letting go of his
ejaculation without any attempt to control
his sexual excitement or delay ejaculation.
A second psychoanalytic explanation
focuses on the man’s unresolved excessive
narcissism during infancy which results in
his placing exaggerated importance on his
penis. This hypothesis might explain the selfishness observed in some rapid ejaculators
who seem unconcerned with pleasuring their
partners [6].
In 1943, (Bernard Schaprio) the notion that
rapid ejaculation was a psychosomatic disorder was introduced [7]. In his view, early ejaculation is a bodily symptom that expresses
the man’s psychological conflict, akin to psychosomatic explanations for headache, backache and stomach pain. Schapiro speculated
that men with rapid ejaculation had specific
‘‘biological organ vulnerabilities’’ which directed the expression of the person’s psychological
conflict. In his view, because men with rapid
ejaculation had ‘‘weakened’’ genitourinary
systems, they became rapid ejaculators rather
than expressing their psychological conflict
through another organ system, e.g. headache.
Psychodynamic theorists consider anxiety
to be the primary causal agent in precipitating
rapid ejaculation. However, anxiety is not a
singular concept; it is used to characterize at
least three different mental phenomena. Anxiety may refer to:
1. a phobic response, like being fearful (i.e.
afraid of the dark, wet, unseen vagina)
2. an affect, the end result of conflict resolution where two contradictory urges are at
play (i.e. the man is angry at his partner, but
feels guilty about directly expressing his
hostility) or
3. anticipatory anxiety commonly referred to
as performance anxiety where preoccupation with sexual failures and poor performance leads to deteriorating sexual
function and avoidance of future sexual
interactions.
Conceptualizing rapid ejaculation in more
of a behavioral/learning perspective, Masters
and Johnson [8] emphasized the concept of
‘‘early learned experience.’’ By reviewing the
case histories of men with rapid ejaculation,
Masters and Johnson noted that many men
described first sexual experiences characterized by haste and nervousness, for example
making love in the backseat of an automobile
or during an encounter with a prostitute.
Masters and Johnson speculated that the
men became conditioned to ejaculate rapidly.
It is not known whether these early conditioning experiences are unique to men with rapid
ejaculation [9].
Kaplan [10] considered ‘‘lack of sexual sensory awareness’’ to be the immediate cause of
rapid ejaculation. She believed that men fail to
develop sufficient feedback regarding their
level of sexual arousal. Such men experience
themselves as going from low levels of arousal
to ejaculation without any awareness.
Absent from any of these theories are compelling notions differentiating the lifelong
and acquired forms of rapid ejaculation.
Obviously more work remains to be done in
clarifying the psychological contributions to
their problem.
The role of performance anxiety
Performance anxiety per se does not generally
cause the initial episode of rapid ejaculation;
however, it is pernicious in maintaining the
dysfunction. By the time patients present for
treatment the initial precipitating event is
often obscured because of the intensity of
the man’s performance anxiety. Performance
anxiety distracts the man from focusing on his
level of arousal, rendering him helpless in
exerting voluntary control over his sexual
arousal and ejaculation. With each failure
performance anxiety heightens, further worsening sexual performance resulting in sexual
avoidance behaviors.
Vol. 3, No. 2, pp. 180–186, June 2006
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Practicing Medicine
Effect on the man and couple
Rapid ejaculation affects both individual and
relationship quality of life (QOL). Men report a
decrease in sexual self-confidence [11]. Moreover, single men or uncommitted men are
reluctant to establish new relationships, and
men in relationships are distressed at not
satisfying their partner, with some worrying
that their partner would be unfaithful to them
because of their sexual dysfunction.
Hartmann et al. [12] characterize men
with rapid ejaculation as preoccupied with
thoughts about controlling their orgasm, with
anxious anticipation of a possible failure,
thoughts about embarrassment and thoughts
about keeping their erection. In contrast, they
found that functional men focused on sexual
arousal and sexual satisfaction.
Intimacy is also negatively affected. Men
with premature ejaculation scored lower on
all aspects of intimacy (emotional, social, sexual, recreational, and intellectual) and had
lower QOL (lower levels of satisfaction in all
areas) than sexually functional men [13].
Premature ejaculation also has a negative
effect on the partner’s quality of life. Lower
partner sexual satisfaction in heterosexual
couples was found where the man had rapid
ejaculation than where the man did not have
the condition [14]. Partners are not just distressed because of the quality of the man’s
sexual performance; they are also upset
because the condition and the man’s associated distress often lead to a rapid and
unwanted interruption of intimacy. Women
are also angry with their premature ejaculation partners because they do not feel that
their concerns have been genuinely ‘‘heard’’
by the man or that he is unwilling ‘‘to fix’’ the
problem. Men overcompensating to ‘‘give their
partners orgasm’’ through manual or oral stimulation is sometimes felt to be a burden
which produces performance anxiety and
further diminishes the partner’s sexual satisfaction. Women feel ambivalence between
expressing their concerns to their partner
because they fear injuring the man’s already
fragile self-esteem and suffering in silence.
Men likewise believe that their partners do
not understand the degree of frustration and
humiliation that they routinely experience.
This disconnection between the men and their
partners is the basis for considerable relation-
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Vol. 3, No. 2, pp. 180–186, June 2006
ship tension. Thus, for men in stable relationships, premature ejaculation should be
recognized as a couple’s issue. All these studies
suggest that the psychosocial effect of premature ejaculation on most patients and partners
has profound psychosocial consequences.
When to offer what
Psychotherapy alone is best reserved for men/
couples where the precipitating and maintaining factors are clearly psychological and/or the
psychosocial obstacles are too great to overcome with pharmacotherapy alone. Examples
of these psychosocial obstacles include:
1. patient variables such as the degree of performance anxiety or presence of depression
2. partner issues such as how the partner
copes with the rapid ejaculation or how
the dysfunction obscures the woman’s
sexual dysfunction (e.g. anorgasmia)
3. interpersonal non-sexual variables such as a
chronically unsatisfying relationship
4. contextual variables including lack of privacy and
5. partner’s expectations from treatment (e.g.
he should last 20 minutes because it takes
me that long to have an orgasm).
Individual psychotherapy is the default
choice for single men not in relationships.
In addition to treating the sexual dysfunction,
therapy must address these men’s reluctance
to enter into new relationships for fear of
humiliating themselves and/or disappointing
the woman. Psychotherapy for rapid ejaculation can only go so far without the presence of
a partner. Obviously, without a partner, the
patient cannot sexually practice what he has
learned nor work through salient interpersonal dynamics. For these men, treatment is
sometimes divided into two phases, treatment
when there is no partner and later resumption
of treatment when he establishes a new relationship.
For men in relationships, individual psychotherapy is recommended when the psychological variables supporting the dysfunction
are thought to be more intrapsychic rather
than interpersonal, e.g. fear of penetrating a
dark, wet, warm vagina or excessive fear of or
hostility to women. These are generally products of unresolved childhood issues that continue to interfere in the man’s adult sexual life.
Practicing Medicine
Individual psychotherapy may also be the
treatment of choice when the relationship is
deemed too chaotic or unworkable, or when
the partner refuses to participate. Individual
treatment in these situations is, of course,
limited given the limitations of the interpersonal environment.
Conjoint psychotherapy is recommended
for men with either lifelong or acquired forms
of premature ejaculation where both partners
are relatively psychologically healthy and
motivated to pursue treatment. Ideally, the
precipitating and maintaining factors can be
explained, the effect of the dysfunction on
both partners can be clarified and interventions directed at him, her and them can be
initiated.
Combined pharmacological and psychological therapy is a new untested paradigm that
may offer the best of both interventions
[1,15,16]. Pharmacotherapy will rapidly delay
ejaculation and allow the man to regain some
sexual confidence. Psychological intervention
will help the man/couple maximize gains from
pharmacotherapy. It seeks to help men/couples overcome the psychosocial obstacles that
interfere with making effective use of the
pharmacological intervention. The man can
be taught to attend to sensations rather than
fear his arousal. He can learn to better pace
himself and expand his sexual repertoire. In
time, he can be weaned from pharmacotherapy and he can implement what he has learned
in therapy. Not all men will be able to give up
the pharmacological intervention. Some, however, will be pleased that ‘‘on their own’’ they
have triumphed over adversity.
Psychotherapy alone
Present day psychotherapy for rapid ejaculation is an integration of psychodynamic, systems, behavioral, and cognitive approaches
within a short-term psychotherapy model
[1,8,10,17–21]. The guiding principles of treatment are to learn to control ejaculation while
understanding the meaning of the symptom
and the context in which it occurs. Psychotherapy/behavioral interventions improve ejaculatory control by helping men/couples to:
1. learn techniques to control and/or delay
ejaculation
2. gain confidence in their sexual performance
3. lessen performance anxiety
4. modify rigid sexual repertoires
5. surmount barriers to intimacy
6. resolve interpersonal issues that precipitate
and maintain the dysfunction
7. come to terms with feelings/thoughts that
interfere with sexual function, and
8. increase communication.
Psychodynamically oriented therapists view
the dysfunction as a metaphor in which the
man/couple are trying to simultaneously conceal and express conflicting aspects of themselves or the relationship. In symbolic terms,
the dysfunction contains a compromised solution to one of life’s dilemmas.
Alternatively, behavior therapists understand the dysfunction as a conditioned
response or a maladaptive response to interpersonal or environmental occurrences. They
provide exercises or homework to help the
man comfortably attend to his sensations
and learn to pace his arousal.
Men fear that by focusing on their sexual
excitement it will cause them to ejaculate even
more quickly. They attempt to diminish or
limit their sexual excitement by wearing
multiple condoms, applying desensitization
ointment, repeatedly masturbating before
intercourse, not allowing partners to stimulate them, or distracting themselves by performing complex mathematical computations
while making love. These tactics, however creative, curtail the pleasures of lovemaking and
are generally unsuccessful.
Men with rapid ejaculation typically
describe two points on their subjective excitement scale, no excitement and the point of
ejaculatory inevitability. They are unable to
perceive or linger in mid-range sexual excitement levels. In treatment, men are instructed
to focus on their sexual arousal. By using
graduated behavioral exercises, they are
taught to identify and become familiar with
intermediate levels of sexual excitement. Successively, beginning with masturbation and
moving progressively through foreplay and
intercourse, they master the ability to linger
in this range, thereby delaying ejaculation.
In addition to teaching men sexual skills
and resolving the interpersonal and intrapsychic issues related to rapid ejaculation, it
Vol. 3, No. 2, pp. 180–186, June 2006
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is also helpful to address the cognitive distortions that help maintain the dysfunction.
Rosen et al. [22] lists eight forms of cognitive
distortions that may interfere with sexual
function. These include:
1. all or nothing thinking, e.g. ‘‘I am a complete failure because I come quickly’’
2. overgeneralization, e.g. ‘‘If I had trouble
controlling my ejaculation last night, I
won’t be able to this morning’’
3. disqualifying the positive, e.g. ‘‘My partner
says our lovemaking is satisfying because
she doesn’t want to hurt my feelings’’
4. mind reading, e.g. ‘‘I don’t need to ask, I
know how she felt about last night’’
5. fortune telling, e.g. ‘‘I am sure things will go
badly tonight’’
6. emotional reasoning, e.g. ‘‘Because a man
feels something is true, it must be’’
7. categorical imperatives, i.e. ‘shoulds’,
‘ought to’ and ‘musts’ dominate the man’s
cognitive processes, and
8. catastrophizing, e.g. ‘‘If I fail tonight my
girlfriend will dump me’’.
Psychoeducational interventions also aim to
rework the behavioral repertoire of the man or
couple, referred to as their sexual script [23].
Men with rapid ejaculation limit foreplay
because they fear becoming too excited. Sex
becomes very mechanical and rigid, yet these
solutions do not help the man to delay ejaculation. By modifying rigid and narrow scripts,
therapists may help couples establish a more
satisfying sexual life.
Resistance
No therapy ever progresses without some resistance on the part of the patient or couple. It is
to be expected. Resistances seek to maintain
the status quo. It is not easy for patients/couples to give up comfortable, yet maladaptive
behaviors. By using confrontation, interpretation, and gentle humor patients can be encouraged to relinquish resistances and ‘‘try on’’
new behavioral and interpersonal routines.
Levine [17] posits four sources of resistance:
1. when the rapid ejaculation and associated
problems maintain a sexual equilibrium
and cover up the female partners sexual
disorder or concern
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2. when the individual or couples harbor
unrealistic expectations about sexual performance
3. when there are major relationship problems
4. when male or female deceit is present.
Psychotherapy outcome studies
Evidenced-based medicine has become the
gold standard for judging the efficacy of psychological or medical interventions. Studies at
the highest level of evidence-based medicine
require moderate to large sample sizes with
designs being randomized, placebo controlled
and double blinded. Sex therapy treatment
outcome studies are uncontrolled and
unblinded; none meet the requirements for
high level evidenced-based studies. What exists
in the literature are reports on small to moderately sized cohorts of subjects who received
different forms of psychological interventions
with limited or no follow-up. In most studies,
active treatment was not compared with placebo, control or wait list groups.
An exception to this standard of small sample sizes and lack of follow-up is Masters and
Johnson’s [8] report on 186 men who were seen
in their quasi-residential model using multiple
treatment techniques including the squeeze
technique sensate focus, individual and conjoint therapy as well as sexual skills and communication training. They reported ‘‘failure
rates’’ of 2.2% and 2.7% immediately posttherapy and at a 5-year follow-up respectively.
Never before, or since has any clinical center
been able to replicate either the initial, or posttreatment, efficacy rates reported by Masters
and Johnson. For example, only 64% of men in
Hawton et al.’s [24] study and 80% of Kaplan’s
cohort [25] were characterized as successful in
overcoming rapid ejaculation immediately
post-therapy.
All studies with long-term follow-up noted a
tendency for men to suffer relapses. In writing
about relapse, Hawton et al. [26] noted that
recurrence of or continuing difficulty with the
presenting sexual problem was commonly
reported by 75% of couples. This caused little
to no concern for 34%. Patients indicated that
they discussed the difficulty with the partner,
practiced the techniques learned during therapy, accepted that difficulties were likely to
recur, and read books about sexuality. In spite
Practicing Medicine
of the decrease in intravaginal ejaculatory
latency time (IELT) over time, patients sexual
satisfaction remained very high.
The concept of relapse prevention has begun
to be incorporated into sex therapy. McCarthy
[27], suggests that therapists schedule periodic
‘‘booster or maintenance’’ sessions following
termination. Patients remark that knowing
that they will be seen again in 6 months keeps
them on target because they know they will
have ‘‘to report’’ on their progress. The followup sessions can also be used to work on any
‘‘glitches’’ that have interfered with their progress.
Combined treatment coaching
The psychological aspects of a combined medical/psychological treatment are different
from psychotherapy alone and are generally
referred to as coaching. Such interventions are
more directive, advice giving, educational and
technique oriented. They target the psychosocial obstacles created after the onset of the
dysfunction such as avoidance of foreplay,
restrictive sexual patterns that are resented
by partners, unwillingness to discuss the problem which itself creates a barrier, etc. The
goals of coaching include:
1. identifying and working through the resistances to medical interventions that lead to
premature discontinuation
2. reducing or eliminating performance anxiety
3. gaining sexual confidence
4. understanding the context in which men/
couples make love, and
5. helping them to modify maladaptive sexual
scripts.
Combined treatment may be especially
helpful when the treatment effects of pharmacotherapy are modest. By lessening the psychosocial obstacles that interfere with treatment
and offering the men/couples methods to
delay ejaculation the effect of pharmacotherapy can be enhanced.
Conclusion
Psychological intervention remains relevant to
treating men and couples with rapid ejaculation. The effect of this dysfunction on the man,
partner and couple are generally profound and
distressing. Psychological intervention in its
traditional form, or in its updated rendering
as combined therapy, offers couples a method
to improve sexual satisfaction, emotional intimacy and relationship satisfaction.
This article is the second in a series of articles on premature ejaculation. Further articles in the
series will be published in future issues of the journal.
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